Public Bill Committee

[Frank Cook in the Chair]
CJ 11 NSPCC
CJ 12 Magistrates Association

Clause 1

Duty to investigate certain deaths

Question proposed, That the clause stand part of the Bill.

Frank Cook: With this it will be convenient to take the following: new clause 9Deaths occurring abroad
(1) The following provisions shall have effect in connection with the investigation of deaths of British subjects occurring abroad.
(2) When the body is returned to a coroners area, the senior coroner must conduct an investigation, when one is appropriate, under the Coroners Act.
(3) When there is no body, or when the body has been buried or cremated outside England or Wales, the relatives of the deceased may, within six months of the death (or the presumed date of the death), apply to the Chief Coroner for an investigation to be held.
(4) It shall be the duty of the UK consular authorities for the country where the death occurred to draw the attention of anyone reporting the death to them to the arrangements for investigation, and to liaise with local public agencies to ensure that all material facts connected with the death are ascertained and communicated..
New clause 19Investigations into deaths: special circumstances
Where there are specific circumstances which make it unlikely that a senior coroner will be able to conduct an investigation or a series of investigations quickly and effectively, bearing in mind the concerns of the victims family or the wider community, the Chief Coroner shall draw the circumstances to the attention of the Lord Chancellor who shall make appropriate arrangements to meet the specific circumstances..

Henry Bellingham: A warm welcome to you, Mr. Cook. It is a pleasure to serve under your chairmanship.
I would like to say a word or two about clause 1, which mirrors the requirements of section 8(1) of the Coroners Act 1988. The requirement to investigate deaths in prison has been altered to apply to deaths where the deceased died while in custody or otherwise in state detention, which makes sense. It is also sensible as it clarifies the situation where the death is in a police station, a mental hospital, an immigration hostel, or whatever. Obviously, there is a requirement that the death be sudden. All in all, clause 1 is a good start to the Bill.
We have identified a problem appertaining to deaths occurring abroad. That is why we have tabled new clause 9, more as a probing exercise than anything else. Obviously, losing a loved one abroad can be incredibly traumatic. We have all come across constituency cases where a family have had a loved one travelling abroadperhaps on a gap year or working abroadwho has had a sudden, appalling accident and a tragic and perhaps unexplained death has occurred. That causes a huge amount of grief. It is dreadful enough to lose a loved one, particularly a young child, but to lose a young child abroad in a strange jurisdiction, with all the problems that might occur as a result, is even more dreadful for the family involved.
I am concerned that there is nothing in the Bill that covers deaths abroad. I accept that clause 1(4)(b) is perhaps a catch-all:
the circumstances of the death are such that there should be an investigation into it.
It does not say that it does not cover deaths abroad. I would like to draw the Committees attention to the draft Bill, which the then Department for Constitutional Affairs published in 2006. A number of clauses in the draft Bill related to deaths outside the United Kingdom.

Jeremy Wright: Does my hon. Friend agree that the difficulty with subsection (4) is that paragraphs (a), (b) and (c) are conjunctive? They relate to a senior coroner who has reason to believe that, first, a death has occurred in or near their jurisdiction; secondly, that the circumstances of that death are such that there should be an investigation; and thirdly, there is a duty to conduct an investigation. Therefore, a death that occurs abroad would almost certainly not be covered by that catch-all in paragraph (b).

Henry Bellingham: My hon. Friend is absolutely right. I was perhaps getting carried away in suggesting that the provision might cover that.
Clause 5(1) of the draft Bill addressed deaths outside the United Kingdom:
The duty of a senior coroner to conduct an investigation into the death of a person under section 1 does not arise where the death occurred outside the United Kingdom.
Clause 6 of the draft Bill was supplemental, and it explained exactly what should happen when a death occurs outside the United Kingdom. That is why new clause 9 makes it crystal clear that in that circumstance there will be a proper investigation:
(1) The following provisions shall have effect in connection with the investigation of deaths of British subjects occurring abroad.
(2) When the body is returned to a coroners area, the senior coroner must conduct an investigation, when one is appropriate, under the Coroners Act.
(3) When there is no body, or when the body has been buried or cremated outside England or Wales, the relatives of the deceased may, within six months of the death (or the presumed date of the death), apply to the Chief Coroner for an investigation to be held.
It spells out what should happen when a death occurs abroad.
We have all come across tragic constituency cases. I had one recently that involved a constituent whose son was murdered in India while carrying out aid work for a charity of which he was a founder member. My constituent contacted to me to press for action:
We have had a total lack of information from the Indian police...the only information we have had is the post mortem result, which was very badly carried out. Our one source of information has been the coroners office, & even they have had a lack of co operation from the Indian police. So I hope you can understand my concern. Without the coroners office & the inquest (which has yet to be held) we would know nothing.
I feel very strongly that when one loses a loved one abroad, the United Kingdom should make every conceivable effort to ensure that some closure is brought to the family. Although my constituent, Mrs. Mary Whitford, points out how competent and understanding the Foreign Office was, she feels that the Bill should spell out what should happen.
The Minister may well point us to provisions in the Bill that allow such inquests to take place as a matter of course. I feel, however, that although clause 1 is a good start to the Bill, new clause 9 is needed to complement it and to clarify what happens when a death occurs abroad.

George Howarth: I want briefly to discuss new clause 19 which stands in the name of my right hon. Friend the Member for Cardiff, South and Penarth.
My hon. Friend the Minister helpfully wrote to members of the Committee in response to a request that I made last week about how the new arrangements would work in cases such as Hillsborough. That was a concern of one of my constituents, who spent a day at the mini-inquest that took place after that event. My right hon. Friends new clause helps in that respect, because it envisages a role for the Lord Chancellor in cases where there might be a question whether sufficient resources are available for a speedy and efficient inquest to take place.
New clause 19 also draws attention to the fact that there might be great concerns on the part of the bereaved or the wider community. I suspect that my right hon. Friend tabled it as a probing amendment, and, although I cannot speak for him, I do not expect that he would wish it to go to a vote. Nevertheless, it is helpful, and I wonder whether the Minister will address those concerns in that context. Perhaps she will put on the record how she envisages the new arrangements applying in cases where there are multiple deaths and legitimate public concerns about the causes of those deaths.

Frank Cook: Order. It may help the Committee if I call to mind that, while it is proper that we debate new clause 19 today, it will not be put to a vote until much later in proceedings. It will be decided today whether clause 1 stands part of the Bill.

Jennifer Willott: We broadly support the bulk of clause 1. I rise to support new clause 9, which has been tabled by the official Opposition. It seems to be a very sensible addition to clause 1. It clarifies what seems to be an omission from the Bill as a whole, particularly since it was flagged up as an issue in the draft Bill that was previously published.
For families that lose a member abroad, there are often even more unanswered questions than there are for families that lose loved ones in the UK. Clearly, an inquest is a very important way in which they can start the grieving process and understand what has really happened. For a lot of families that were not present at the time and that played no role in what happened to their family member, the inquest is a really important part of their grieving process. I would be grateful if the Minister were to make it clear whether the Government intend to clarify the process for deaths abroad in order to ensure that it is made much easier to see who is responsible and that the deaths get investigated properly by a coroner at an open inquest, so that their families can get the answers to some of their questions.
I am sure that no one in Committee disagrees with the intention behind new clause 9. If there is no mechanism to tackle a backlog and deal quickly with circumstances where there are a significant number of deathsas happened in Hillsborough, which the right hon. Member for Knowsley, North and Sefton, East has highlightedit can cause untold hurt and distress to families. I am not completely convinced that the wording of new clause 19 is the right way to go, but I am sure that the Minister will be able to let us know the Governments thoughts on how to manage such circumstances to ensure that families get the answers that they need as soon as possible.
The only other point that I want to raise concerns clause 1. We welcome the extension of the provision from when death occurs in prison to a broader list of circumstancesfor example, areas of custody. There have been increasing concerns in the past couple of years about immigration detention centres, where there have been increasing numbers of reports of violence and of inmates experiencing problems at the hands of some guards. As I understand it, fortunately there has not been a death so far in an immigration detention centre, but it is welcome that these provisions cover those institutions, so we will be prepared if there is an unfortunate incident in the future.
We also welcome the removal of the requirement for the death to be sudden. There are lots of circumstances where a death is not sudden but is still deeply suspicious. Broadening the grounds on which an inquest can be called, and making sure that it covers as many of the possibilities as possible, is a positive way forward.

Madeleine Moon: I rise to discuss new clause 19. In looking at this Bill, we have discussed the role of the coroner in explaining the how of someones death. Often for the family, the explanation that they are seeking is the whyit is their desperate need to know why their family member died, particularly in cases of suicide.
I have mentioned several times my interest in the promotion of psychological autopsies and their role in helping to prevent suicide in wider society. We currently have in the Department of Health a national suicide audit toolkit. The toolkit is voluntaryit is for individual health authorities to design and use in their own way. It does not collect national data, and it does not pose a national strategy for examining suicides.
My right hon. Friend the Member for Knowsley, North and Sefton, East spoke about events relating to Hillsborough. I do not consider the events in Bridgend to be of the same order as those at Hillsborough, but they pose similar issues of national concern as to what was happening and why. They provide us with an opportunity, as a society, to understand what we can do to prevent the needless deaths of young people. There have been studies of suicide autopsies, particularly by Hawton and Appleby, and a structure has been created for carrying out such autopsies.
New clause 19 offers us the opportunity to implement suicide autopsies nationally, so that we can gather data nationally, develop understanding and provide local authorities and local health authorities with the information, advice and guidance that they need to provide new services and ways of operating that would prevent clusters of deaths in the future.
I want to summarise the sort of information that is gathered. The study carried out by Appleby includes data from interviews with families and friends carried out by an experienced mental health nurse, along with an examination of inquest notes, medical records, psychiatric notes, social networks, demographics, previous self-harma particularly important issue when we are looking at suicideeducation, work and certain life events. In cases of suicide, the motivator is often a life event in the previous three monthsin many cases, it occurs in the previous week. Finally, it is important to examine the role of alcohol and substance misuse.
New clause 19 offers us an opportunity to take away from the local inquest into an individual death information that may well answer the question of how, which will enable us to look at the wider societal need to prevent further deaths and clusters of deaths. Hopefully that also answers for the family the much wider question of why.

Tim Boswell: I am grateful for the opportunity to follow the hon. Member for Bridgend, who obviously has particular constituency experience. The debate to date has been characterised by a serious tone, as one would expect, but it has also begun to bring out two essential points in relation to inquests.
First, inquests have a vital role in providing closure for the family and, to be honest about it, in certain cases they expose circumstances which may or may not give rise to subsequent private legal action. But that is not the only motive, by any means. Secondly, as the hon. Lady has just said, the coroners inquest and subsequent report may bring out public interest aspects of the case. Anyone who has ever been involved in any way would desire to ensure that that set of circumstances is, if possible, avoided and not replicated, and that lessons are learned for the futurewe all approach this matter with that point in mind. I have signed new clause 9, which was tabled and elegantly discussed by my hon. Friend the Member for North-West Norfolk, in relation to deaths occurring abroad, which I will primarily discuss.
It is right to treat new clause 9 as a probing amendment, and we look forward to the Ministers response. As I read it, which is imperfectly as a lay person, the issue is not really rehearsed in the Bill in the way in which it was in the draft Bill. There appears to be an interesting disagreement of interpretation. The Library research paper implies that the thinking in the draft Bill, which would have limited inquests carried out abroad, has been dropped in favour of more or less leaving the status quo. I accept, if only by faith, that there will still be provision for inquests in relation to deaths abroad, but I wait for the Ministers assurance to confirm that. For the reasons that I have given and wish to give, that is very important, and perhaps the Minister will explain the thinking on that point.
I knowagain, the Library research paper refers to thisthat there are some doubts. Without making use of an international provisionI think that there is no Hague convention in this areano British court or coroner could draw on or compel foreign authorities to provide or carry out essential procedures, such as post mortems, in a consistent way or, if the event has occurred within British jurisdiction, according to their wishes. There is a need to clarify the powers and circumstances under which a coroner may proceed in relation to a death abroad. In new clause 9, we provide that on return to a coroners area, the senior coroner will conductindeed, must conductan investigation, if appropriate, under the Coroners Act 1988. In effect, that will bring the matter into British jurisdiction. New clause 9(3) addresses a situation where there is no body, or where the body has been disposed of before return to the jurisdiction, and subsequently, the familys right to apply for an inquest. There is a separate provision in relation to consular authorities.
Perhaps I can speak in general terms about that matter. As I understand the thinking in relation to the draft Coroners Bill, one of the problems identified by the Ministry of Justice is that one cannot compel the giving of evidence. The suggestion is that the chief coroner would in effect, stand in and act as the internationally representative authority and would request his opposite number in another jurisdiction to provide the informationideally, the information would be provided in a reasonably coherent and standardised form. That role is terribly important, because otherwise the nature of an inquesteven if carried out in the UK into a death occurring abroadmay be somewhat impaired and more difficult to conclude. I modestly suggested that point to my hon. Friend the Member for North-West Norfolk for his new clause. In terms of the thinking behind the charter for the bereaved and in the interests of the families involved, we should take a very close look at the ability of the consular service to advise family members as to their rights and responsibilities, if a death occurs abroad.
In conclusion, I would like to say a word from my own experience. Our constituents often feelthey sometimes write to us rather bitterly about thisthat as Members of Parliament, we do not know anything about difficulties. If we have been MPs for any length of time, we know a great deal about the difficulties faced by our constituents, and, how ever sad they are for the individuals, they are invaluable in bringing up cases and problems. It just so happens that in this particular caseit is now half a lifetime ago, since I refer to events in March and April 1974I have some personal experience of a death abroad involving a close member of my own family. To compound matters, the particular accident leading to subsequent death took place on a British-registered ship in United States territorial watersthe lawyers in Committee may wish to reflect on the particular interaction and conflict of laws and subsequent private litigation on the matter. But I do not intend to indulge myself or reveal any further details.
I make no criticism of the consular authorities, who were aware of the accident and subsequently notified of the death. A British death certificate was issued, as well as an American death certificate. Lessons could be learned from the handling of that case. We ended up with a situation where the US authorities conductedwithout our involvementwhat might be called a peremptory inquest into the circumstances of death. However, no substantive investigation of the facts took place either there or in the United Kingdom, other than what we were able to obtain through legal process.
It was suggested at the time that we might be able to ask for an inquest in the UK, but I never saw any specification in writing. We did not proceed with that, and I wish to say no more about it. But what I do want to say, informed by my experience of those many years agoit is in the past, and I do not wish to go back to itis that even relatively sophisticated people are very vulnerable in such circumstances, where they may find themselves in a forest of jurisdiction. It is self-evident that in a highly developed country with good medical and legal services, the same working language as ours and broadly the same legal system, it was easier to deal with the situation than it must have been in the case referred to by my hon. Friend the Member for North-West Norfolk, which involved a road accident in India with different languages and different public expectations.
It is important that we should be able, so far as we can, to offer the same kinds of services to bereaved families through the consular service and the activities of the chief coroner. We should seek an exchange of information in order to investigate such circumstances, where it is appropriate, not to a higher standard, but ideally to the same standard or to a broadly equivalent standard. That is important not only for the familiesI have mentioned that the event actually took place on a United Kingdom-registered ship, and there were issues of potential liability and so forthbut so that lessons of failure or success can be learned for the future. As I have said, I do not want to pursue that point, but I think that it is valuableit has certainly been valuable for me to at least get that off my chest. Nearly all bereaved families who have an interest in this Bill would say that whatever happened can actually serve to advance a better understanding of the circumstances and better practice for the future. That, frankly, is what we would all wish to see.

Bridget Prentice: This has been a very intelligent and thoughtful short debate on clause 1 and the two new clauses. In my response, I hope that I can reassure the Committee that the new clauses themselves are unnecessary. I accept the assurance of the hon. Member for North-West Norfolk that new clause 9 is a probing new clause.
I will deal first with situations where a death occurs abroad and the body is returned to England or Wales. I believe that the powers suggested in new clause 19 already exist in clause 1. What the hon. Member for Rugby and Kenilworth said about subsection (4) being conjunctive is true. However, once the coroner is made aware that the body of a deceased person has arrived in his areano matter where the death occurredthen he has the duty to carry out an investigation. It does not matter whether the death occurs abroad or even in another part of the UK; if the body is returned to the jurisdiction of the coroner, then the duty exists.
The hon. Member for Daventry and my right hon. Friend the Member for Knowsley, North and Sefton East have highlighted some of the problems in cases overseas in particular, getting the necessary information to carry out the investigation. In that situation, the chief coroner will have a central role in establishing relationships with the relevant authorities overseas in order to act on behalf of the senior coroners, where such information is required. At present, that liaison is undertaken by the Foreign Office or sometimes by the UK central authority.
I have spoken to someone who was in the Foreign Office and who dealt with deaths overseas, such as the tsunami in south-east Asia. That person was involved in supporting families and was party to ensuring that inquests took place properly.

Tim Boswell: Does the Minister accept that although the Foreign Office did an amazing job in the exceptional circumstance of the tsunami, one of the difficulties about individual cases is that they will be relatively rare? Therefore, with the greatest respect to consular authorities, who have many other commitments, they might not have day-to-day experience, so should they not simply refer people to the relevant experts at headquarters who can advise them?

Bridget Prentice: The hon. Gentleman has made a good point. I agree that the work done by the Foreign and Commonwealth Office and consular offices has been outstanding in those cases. However, he is rightand that is why the chief coroners role is so important. Apart from anything else, many overseas countries do not have a coronial service or anything similar. Therefore the chief coroners role would be central to acting on behalf of all coroners in respect of deaths that occur abroad, and establishing relationships with other countries in order to get the desired information.

Tim Boswell: In a sense, this is an afterthought to my earlier remarks: will the Minister consider the possibility that where a death is reported to the consular authorities overseas and a death certificate is issued, some notification should be made to the UK authoritiesperhaps to the chief coronerso that there could be some clearance to decide whether or not an inquest should take place in the UK?

Bridget Prentice: I will certainly consider that. I will come to some of the practicalitiesI do not want to consider too many what if questions, because we can find ourselves in fantasy land if we go too far down that road. When I refer to the chief coroners role of establishing relationships with foreign authorities, I do not refer to military personnel on active service, for whom we have properly established arrangements, which will continue to operate as they do now.

Henry Bellingham: The Minister mentioned the tsunami. I quote from page 21 of the explanatory notes on clause 5 of the draft Bill:
The purpose of this clause and clause 6 is to get the balance right in terms of sensitivity towards bereaved people while at the same time making sure that coroners are not being asked to carry out investigations which will add nothing to the knowledge of how someone came by their death. An example of the latter could be those who tragically died in the Asian tsunami in 2004 where the cause of death was clear.
Were the Government thinking at the time that when you have a large number of deaths caused by one natural disaster there should not be individual inquests? Is the Minister saying that that train of thought has been replaced by the current thinking, which is that all such deaths would probably have had separate inquests?

Bridget Prentice: The latter is correct. It relates to the comments of my right hon. Friend the Member for Knowsley, North and Sefton, East about the Hillsborough case. That would be an instance in which the chief coroner could give direction as to whether inquests should be held as a wholeconsidering many deaths togetheror individual deaths should be investigated separately. For example, we want to use different jurisdictions to deal with military deaths abroad, so that inquests take place closer to where the family lives. That would be one example of the chief coroner being able to intervene. When many deaths occur due to a natural disaster abroad, the chief coroner could make that kind of direction.

George Howarth: I have listened carefully to my hon. Friend. My concern about dealing with those who died in a disaster as one event is that, although the cause of death might be the same in every case, the circumstances might vary from case to case. In the example of Hillsborough, everybody died as a result of the lack of proper policing, as the Taylor inquiry established. However, had medical attention been received earlier, some of them might have survived. It is important for the bereaved that such issues are explored, and that can only be done through individual cases, not by treating them all as one class of case.

Bridget Prentice: I assure my right hon. Friend that I understand exactly his point, which the chief coroner would have to take cognisance of. In the investigation after such a disaster, it would be important for the chief coroner to reflect on those kinds of issues, and if appropriate to direct that individual inquests need to take place.
I turn to that part of the new clause that deals with deaths overseas where there is no body or where it has been buried or cremated. In reference to the hon. Member for Daventrys intervention, there are already arrangements in place to register deaths in order to accommodate the circumstances in which a death has occurred but the body is irrecoverable. The bereaved family could make an application for a leave to swear death order, based on evidence. If the court makes that order, probate can go forward. To some extent, that is part of the closure procedure for a family. That is what was used in the 2004 tsunami. Special arrangements were made for consular death certificates to be issued where the bodies were not recovered, on the basis of evidence gathered by British police teams in their own special investigation.
If the body is buried or cremated outside England and Wales and has never been situated in England and Wales, obvious practical difficulties could hamper a coroners investigation and certainly make it of pretty dubious value. I am not convinced that that would not be a recipe for further dissatisfaction for a bereaved family.

Tim Boswell: I want to refer only briefly to my personal experience. There was no question as to the immediately proximate circumstancesviz, a head injury. The concern would be more with the kind of narrative verdict that a coroner in Britain could now generate about the alleged negligence or otherwise that led to the circumstances in which the family member was injured. I am not at all clear that an entirely satisfactory issuing of a foreign death certificate would not be in order, but it precluded, or appeared to preclude, a separate investigation as to the antecedent circumstances, which were clearly more important as far as we were concerned.

Bridget Prentice: I take the hon. Gentlemans point. I hope, however, that that is covered under clause 1 by the different duties that the senior coroners and the chief coroner have. The duty to investigate
does not arise because of the destruction, loss or absence of the body.
Under subsection (4), the senior coroner has a power to report to the chief coroner if there is good evidence that a death has occurred. The chief coroner could weigh up the evidence and decide whether to direct an investigation into the death.

Jeremy Wright: I return to the point I made while interviewing my hon. Friend the Member for North-West Norfolk. The provision to which the Minister refers applies only if the death has occurred in or near the coroners areait does not deal with the point that my hon. Friend the Member for Daventry raises about deaths that occur abroad.
The Minister is right that there will be some occasions when the investigation by the coroner of a death occurring abroadwhere the coroner does not have access to the bodywill be unsatisfactory. Could I ask her to consider subsection (3) of new clause 9, which says that relatives of the deceased may
apply to the Chief Coroner for an investigation to be held.
That does not oblige the chief coroner to carry out such an investigation, but it enables the chief coroner to consider such an application where it is appropriate for him to do so.

Bridget Prentice: The hon. Gentleman is right. In the situation described by the hon. Member for Daventry, the bereaved family can make that application to the chief coroner. Depending on the circumstances, he or she could then direct that an investigation be held. I think that that covers as many cases as possible without allowing outlandish ideas. We are trying to be as practical as possible.

Tim Boswell: I am not sure whether the Minister wants to say something about the final subsection of the new clause. It would help a lot, and it would be entirely in the spirit of the charter for the bereaved, if the consular authorities at least had the standard practice of issuing to families a piece of paper explaining their rights and recourse. They could bring that back with them and, on reflection, consider whether or not they wished to take the matter forward.

Bridget Prentice: That is a practical suggestion, which I will take forward. I strongly believe that we should give people as much information about those situations as possible and allow them to take responsibility for making a decision that is best for them. All coroners will have to provide statistical information to the chief coronerfurther information of that nature will be helpful to himas will the medical adviser, who will be able to interpret some of that statistical information on behalf of the chief coroner. That will be helpful too.
I understand that the hon. Member for North-West Norfolk tabled this as a probing amendment. As he stated, the idea is to help bereaved families whose loved ones have died overseas to find closure through the coroners investigation. That is particularly the case where there is no body or where the body has been buried or cremated overseas. I hope that the procedures that I have set out provide that reassurance.
On new clause 19 tabled by my right hon. Friend the Member for Cardiff, South and Penarth, the chief coroner already has the power, under clause 3, to direct coroner resources to deal with delays and backlogs. In a case of mass fatalities, a local authority can appoint further deputies to help out. It is important to put on record that the changes made in this clause that give that duty and responsibility to the chief coroner rather than the Lord Chancellor are, as I hope that everyone would agree, the right road to go down. As the chief coroner will have overall responsibility for the day-to-day running of the coroner service, he should be more aware of what the problems may be and how best to allocate resources.
On the comments of my hon. Friend the Member for Bridgend about psychological autopsies, the charter explicitly states that the chief coroner will set out minimum standards in relation to specific deaths. That could include advice on the use of psychological autopsiesI do not preclude that possibility in any way.

Henry Bellingham: I am grateful to the Minister for her explanation. I want to clarify a couple of points. To recap quickly, the clauses in the draft Bill prevented an inquest into a person killed abroad unless certain circumstances applied, including, for example, if they were serving in the armed forces. The draft Bill said that there will not normally be an inquest into deaths occurring abroad unless certain factors apply, and stated that the coroner had the power to refer a death occurring abroad to the chief coroner, who could then order an investigation. Is this Bill likely to lead to more inquests into deaths abroad than would have been the case under the draft Bill? All hon. Members have received correspondence from worried constituents who want to know whether getting such inquests will become more difficult. Can she explain to the Committeeshe has not done this so farthe difference between what is in the Bill before us, and what was in the draft Bill? That would put our minds at rest, and enable me to conclude that the new clause is not necessary.

Bridget Prentice: The provision in the draft Bill and in this Bill is not different. As far as deaths abroad are concerned, where there is no body returned to England or Wales, the policy is exactly the same. The language is differentit is expressed slightly differently in this Bill. To reassure the hon. Gentleman, deaths will be investigated if they would have been investigated under the present system. With the changes in the legislation and the widening in clause 1, there will probably be more inquests on deaths abroad than has occurred up to now. However, it would not be possible to put a figure on it. I reassure him and the Committee that we are giving bereaved families more scope to have closure through the inquest system than they have at the moment.

Henry Bellingham: The Minister is therefore saying that the more widely drafted wording of subsection (4)(b) replaces two whole clauses in the draft Bill. The Government are looking for a more flexible, easier-to-understand system, which provides more scope and flexibility for the chief coroner.

Bridget Prentice: Absolutely spot on.

Question put and agreed to.

Clause 1 accordingly ordered to stand part of the Bill.

Clause 2

Request for other coroner to conduct investigation

Question proposed, That the clause stand part of the Bill.

Henry Bellingham: Clause 2 is similar to section 14 of the Coroners Act 1988, which allows a coroner in one district to ask a coroner from another district to assume jurisdiction over an investigationin effect, to take over. One of the discussions that has been going on relates to the costs of transferring inquests to another coroner area. Will the Minister tell the Committee the situation regarding costs? Will they be paid entirely by the coroner area where the inquest takes place after the transfer, or will the original coroner area pay some of those costs?
This clause is good news as far as military inquests are concerned, because we have all been concerned about the situation relating to the bodies of tragically deceased servicemen and women who have been flown into RAF Lyneham in Wiltshire and RAF Brize Norton in Oxfordshire. Military inquests have been taking place within Wiltshire and Oxfordshire and carried out by the local county coroners. They have been carried out extremely effectively, but the problem is that significant delays have built up, and that has been a concern to both the coroners in those areas and the families involved. Why can the families notas a matter of courseelect to have the inquest in their home town? Under clause 2, according to my reading of it, families could speak to the coroner, and the coroner could decide to request that another coroner carries out the investigation. That coroner could be the coroner for the home town or city of the families involved. The inquest would therefore take place, probably as a matter of course, in either Wiltshire or Oxfordshire, but when pressures build up and delays take place, there could be an easy transfer to another city or area.
Members on both sides of the Committee will have dealt with situations in which families who have lost loved ones in either Iraq or Afghanistan have found it extremely inconvenient and difficult to get to Wiltshire or Oxfordshire. Recently, a family wrote to me to ask why an inquest could not have taken place in Norfolk; I was sympathetic to that. Does the clause make that eventuality more likely and more easily brought about, and will the Minister answer my question about costs?

Tim Boswell: Briefly, may I support my hon. Friend in his queries? Two relevant cases have affected me, as it happens, because of the strange geographical situation I find myself in. I live in the extreme south-west of Northamptonshire. I sometimes have difficulty persuading my constituents that I have lived in my constituency for 40 years, which I have, because I have an Oxfordshire post code. In addition, a motorway immediately adjacent to where I live is policed not by Northamptonshire police, but, by arrangement, by Thames Valley police, because it would clearly be stupid to break up the responsibility for a two-mile stretch of somebody elses jurisdiction. On one occasion, less than a mile from my home, a fatality took place in which a cyclist fell from the motorway down on to the road below. That created a jurisdiction issue. Subsequently, a former employeewhom we took on part time to look after livestock on my farm, which goes right down to the county boundary and crosses it at one pointwas sadly afflicted, after a life of perfect health, by a sudden heart attack. We found him dead in the field, and it was difficult not only in personal termsobviouslybut in terms of sorting out the coronial jurisdiction. Everybody was helpful, but the body was removed to Northampton because the death had occurred in Northamptonshire, notwithstanding that the widow lived within two miles in Oxfordshire and all the interests were down there. Within the spirit of what the Minister seeks to do, I seek an understandingnot in those circumstances, because it is a matter of judgmentthat such provision should become more frequent than it has been in the past. To stray briefly into clause 3, if there are difficulties and the coroner is stroppy and reluctant to forgo jurisdiction, the chief coroner might wish to address that matter.
If there is to be a transfer, it is terribly important that the process is cleared quickly for the families involved, so that they, and all the various authorities, know whom they are dealing withwith regard to receiving permission to dispose of the body, issuing death certificates and so forth. We do not want, as we have occasionally had from the GovernmentI will not stray into that nowa commitment to an administrative system that gives rise to further delay and distress. I hope that the Minister can assure us that the provision will work seamlessly and swiftly to ensure that the inquest and inquiries are carried out in the most convenient and expeditious place.

Bridget Prentice: Clause 2 will allow the senior coroner, who has the duty to conduct the investigation under clause 1, to ask another senior coroner to conduct such an investigation.
I want to touch briefly on military inquests, and endorse the comments of the hon. Member for North-West Norfolk about Oxfordshire and Wiltshire, which have done an outstanding job in clearing the backlog of inquests on our servicemen and women who have died in Iraq, Afghanistan or on other active service overseas. Along with the Ministry of Defence, I report regularly to the House on how those inquests are progressing.

Tim Boswell: The Minister gives me the opportunity of putting on the recordif she will accept itmy thanks to her for the report she gave in a written answer on 2 February. It would be fair to say that, at least on the coronial side, the Government are beginning to get their act together. This will be a good token, and, I hope, the precursor of a constructive debate later.

Bridget Prentice: I appreciate the hon. Gentlemans comments. The MOD has also moved a great deal in trying to be far more supportive and flexible in getting the information that we need for those investigations to be carried out.
I hope that I can give both hon. Gentlemen the assurances that they need. There are a number of reasons why a senior coroner might ask another coroner to take on an investigation. The most common reason will likely be that the family so wishes it. If the death occurred in one jurisdiction and the body lies there, but the family lives in an entirely different part of the country, it would be appropriate. I assume that the coroner would be perfectly entitled to ask a colleague to take on that investigation. There might be other reasons. The coroner might know the deceased person and therefore feel that it would not be appropriate to conduct the investigation. The important thing is that the coroner should come to such arrangements so that bereaved families receive the service they deserve and, as the hon. Member for Daventry asked, the inquest is conducted as quickly as possible. The clause replicates broadly section 4 of the Coroners Act 1988.
I am confident that coroners will act reasonably, accommodate requests from their colleagues and help where they are able; they do that at the moment. However, the fact that the chief coroner must be informed that a request has been made will ensure that such requests are monitored, and he will be able to see whether anyone isor appears to bemisusing the system. Therefore, the chief coroner will be able to intervene, as under clause 3, at an early stage if there are disputes; that will be part of his leadership role.
I turn to the issue of cost. Who will pay will depend on the circumstances; generally it will be the transferring area. However, that will not apply to military inquests, where the local area will be expected to pay. In general, the policy on military deaths is that single deaths will be transferred but multiple deaths will not, for reasons that will be obvious to the Committee.

Henry Bellingham: I want to ask the Minister one final question about military deaths. Is it fair to say that, hitherto, families have had problems getting the inquest transferred to their home cities? If that has been the case, is the Minister confident that her good offices will have prevailed on the relevant authorities to ensure that if families now want a transfer, that will always be allowed? The Bill makes clear exactly what the procedure is.

Bridget Prentice: Certainly, families have had problems in getting cases transferred, because the law did not allow for it. The law states that the inquest must take place in the jurisdiction where the body is held. That is one of the difficulties in Scotland regarding military deaths of Scottish personnel. It has a ridiculous situation whereby aeroplanes must touch down at Brize Norton or Lyneham for an inquest of a Scottish serviceman or woman to be heldScotland simply does not have a coronial system in the same way that we do. Clause 2 is therefore important.

Question put and agreed to.

Clause 2 accordingly ordered to stand part of the Bill.

Clause 3

Direction for other coroner to conduct investigation

Question proposed, That the clause stand part of the Bill.

Henry Bellingham: Clause 3 gives the chief coroner the power to direct another senior coroner to conduct investigations. I would be grateful if the Minister will give us examples of where this might be needed. Certainly, one can think of appalling accidents and disasters such as Hillsborough or Hungerford, where there was a tragic mass shooting in 1988. In those cases, the chief coroner would want to make sure that the inquests were moved to different areasperhaps out of that particular county. Will the Minister give examples where a chief coroner might use the powers? Also, who will bear the cost of transfers? The chief coroner might direct an inquest which takes place away from the area in which a disaster happened; there would be substantial cost. Would the transferring coronial area pay, or would that fall to the area to which the inquest was transferred? The implications are significant, because we might be talking about an inquest lasting for many weeks and costing a large amount of money.

Jennifer Willott: Clause 3 gives chief coroners the power to co-ordinate work in different coronial areas. I would like to highlight the fact that, although this is a welcome provisionas was clause 2it is only needed because the Government have dropped the proposal to have a centrally co-ordinated national coronial service. I would be grateful if the Minister were to respond to a number of concerns about that element.
This clause allows for a sharing of burdens and workload across coronial areas, if there is an issue with workload, backlog and so on. There have clearly been significant problems in the past in certain areasin some areas, there is still a significant problem. I asked a parliamentary question in December 2006I do not have more up-to-date figureswhen some outstanding cases had been awaiting an inquest for more than five years, and some had been waiting for 10 years. That causes severe stress and distress for the victims families.
Although the provisions in this clause would make a difference, I am disappointed that the Government have not decided to go ahead with a single, national coroners service. A properly co-ordinated service would enable fair sharing of the burden of work, so backlogs would arise less frequently. It would also be able to tackle the significant issue of funding for coroners areaswe heard evidence on that in the sittings that we held last week. It is clear that funding and the provision of resources other than fundingspace, offices and services for witnesses attending an inquestare patchy across the country. We heard evidence from the coroner from Liverpool, who clearly has palatial suites and is very happy with his lot in life. However, I have visited the Cardiff coroners offices in the court in my constituency, which is, I would say, probably closer to the other end of the scale, given that it is located in a city centre and has a significant workload.
The coroner in Cardiff is a paired operation between the Vale of Glamorgan and Cardiff county council. Most deaths occur in Cardiff, and the Vale of Glamorgan is reluctant to provide a lot of resources from which its residents will not benefit. The provision in Cardiff is in the central police station. The way in which you are greeted and how welcome you are made to feel depends on the desk sergeant. There are no toilet facilities for the jurors, no proper waiting area for the witnesses, very cramped offices for the coroners and so on. The provision would tackle some of the backlog issues, but it will do nothing to tackle that, because the power for the chief coroner to do so is not provided in this clause.
Regarding the backlog that clause 3 would tackle, serious issues are built into the system by the funding being provided on a local basis by local authorities. For example, the coroner in Cardiff is employed on a part-time basis, despite the fact that she actually works full time off her own batshe is only paid to work part time. That is the only way that she has been able to manage the backlog. Clearly, the provisions in clause 3 would tackle that in some way, but I would be grateful if the Minister were to answer why the Government decided not to implement a fully national coroners service. Some of the fundamental problems that are built into the current system are not being tackled by this Bill and will therefore continue.

Bridget Prentice: First, let me give some examples of when or why the chief coroner may direct that an inquest be held in a different area. One will be to deal with localised backlogs. I was a bit worried about what the hon. Member for Cardiff, Central was saying. I hope that she is not trying to give the impression that backlogs are springing up all over the country, because I do not believe that that is the case. However, backlogs and unexpected demand can occurthe hon. Member for North-West Norfolk gave the example of a multiple shooting. That might create a backlog and could be a case where a chief coroner directs that investigations be held in another area.
Another example is when the inquests took place into the deaths in the London bombings. They were taken by one coroner, which means that the coroners other work may have to be sent elsewhere. The main reason for that is to make sure that backlogs do not occur and that bereaved families get prompt investigations. A further example is where several deaths occur but the families live in different areas. In this case, the chief coroner may decide to allocate the inquest to a particular place that is most convenient for the families involved.

David Kidney: A moment ago, we heard about resources and backlogs. Should we not assert as a matter of principle that in the main the inquest should be in the place where the body is and where the death has occurred? That is the position in the Bill, and it has been the case in the history of the coronial service for ever. It should never simply happen for administrative convenience. In relation to clause 2, the hon. Member for North-West Norfolk asked about families that say, We think the inquest should be here, where we and a lot of the witnesses are, rather than there, where the death occurred. Is that a case where the chief coroner might be asked to step in, if the senior coroner did not agree to the familys request?

Bridget Prentice: That is a very good example of exactly the role that the chief coroner would have under clause 3, and given that direction

Tim Boswell: Will the Minister confirm to the Committee that any one of these decisions on an instruction would be judicially reviewable, if somebody felt that that were appropriate?

Bridget Prentice: Yes, such decisions would be judicially reviewable. The chief coroner will have the power to make those directions, irrespective of the views of the receiving coroner. That brings me to the issue of costs. I do not wish to repeat what I said earlierbasically, my position is the same as stated in a previous debate.
I want to turn to what the hon. Member for Cardiff, Central said about the relationship between different local authorities. I know we will come to this in greater detail under clause 23, when we will specifically discuss resources. I suggest to the hon. Lady that, as Cardiff city council is run by the Liberal Democrats, she might want to have a word about properly funding the coroners service in that area. I am sorry to bring party politics into it, but I could not help it.

Jeremy Wright: May I ask the Minister again about cost? I appreciate that she has told us that the position is the same as she outlined in relation to clause 2. However, I hope that she accepts that there is one important difference. Under clause 2, where a case is transferred from coroner A to coroner B, coroner B has to agree to carry out that inquest, and they may decide not to do so on the basis of inadequate resources. Under clause 3, as I read it, there is no opportunity for the receiving coroner, if I may put it that way, to refuse a request or instruction from the chief coroner. That is surely a difference in relation to resources. Will the Minister help us on the consequences for a coroner who believes that they have inadequate resources but who has been instructed by the chief coroner to take on an additional inquest?

Bridget Prentice: The hon. Gentleman is right in his description of the difference between clauses 2 and 3. Regulations will be made later in relation to costs, which will be consulted on. I will say two further things. First, the transferring area will generally pay. Secondly, if a receiving coroner felt that they did not have the proper resources, one hopes that a reasonable chief coroner would not try to send investigations to an area that has its own problems with backlogs or whatever. The reasonable test would have to come into effect, and I hope that in that situation the chief coroner would not direct to an area where it would not be appropriate in those circumstances.

Question put and agreed to.

Clause 3 accordingly ordered to stand part of the Bill.

Clause 4

Discontinuance where cause of death revealed by post-mortem examination

Question proposed, That the clause stand part of the Bill.

Henry Bellingham: Clause 4 is fairly straightforward, because it relates to the discontinuation of an investigation when the cause of death is revealed by a post-mortem. It would be helpful if the Minister could elaborate a bit on the clause, and perhaps give us some examples that we can have a look at.
Perhaps it is my lack of in-depth reading of the clause, but I am not 100 per cent. clear about whether there will be an appeal procedure in this particular case. The family may well feel unhappy about the outcome and that, despite what has come out of a post-mortem, questions still need to be asked and lessons learned for the future. They may be very keen to still have a full inquest. I do not see anything in the clause that gives immediate rise to the opportunity for an appeal, if the family feel strongly about it. Of course, they could write to the chief coroner, who could use their powers in other parts of the Bill, but would it not be easier to cover it as part of this clause?

Jennifer Willott: I have a quick question for the Minister about the clause. My question specifically relates to subsection (4), which calls on the coroner to provide a written explanation, if requested, of why the inquest has been discontinued. Clearly, giving an explanation is to be welcomed, but I want to ensure that, as with all Government missives, any written explanations are cleared through a plain English directive, because some Government letters are easier to understand than others. In a circumstance such as this, clearly it needs to be easy for the family to understand. I would also be grateful if the Minister were to clarify whether there will be the opportunity for the interested person to raise any questions or to get further clarification, if they do not understand all the issues highlighted by the coroner. Clearly, making people happy and ensuring that their fears and concerns have been laid to rest is important.

Bridget Prentice: I hope that I can give the hon. Lady that assurance. I am a great campaigner for plain English in all Government documents. I have not been successful on many occasions, but split infinitives and aberrant apostrophes are included in my campaign for making sure that people get the information that they need. Of course, people can return to the coroner and ask for further information. I know that many coroners often invite families to see them and talk through the situation, which is often much better than receiving something in writing.
An awful lot of deaths are referred to the coroner because the cause of death is unknown, but then a post-mortem reveals natural causes and that there is a perfectly natural explanation. If that happens, there really is no need for the coroner to investigate the death further. Sometimes, investigating a death further can cause additional stress and concern to bereaved families. That is the reason why this clause is set out as it is, but one has to be sure that it is only the appropriate cases that are discontinued. If it is suspected that the death was violent or unnatural, or if it occurred in custody or in other forms of detention, those cases must progress to an inquest.
Finally, on the point made by the hon. Member for North-West Norfolk, clause 30(2)(b) provides an appeal system for families, if an inquest has been discontinued.

Question put and agreed to.

Clause 4 accordingly ordered to stand part of the Bill.

Clause 5

Matters to be ascertained

Henry Bellingham: I beg to move amendment 39, in clause 5, page 3, line 40, leave out subsection (2).

Frank Cook: With this it will be convenient to discuss the following: amendment 112, in clause 5, page 3, line 40, after necessary, insert in the interests of justice or.
Amendment 113, in clause 5, page 4, line 1, after ascertaining, insert 
(i) .
Amendment 114, in clause 5, page 4, line 2, at end insert
(ii) whether and to what extent systematic failings were a factor in death;
(iii) whether appropriate precautions could have been taken to prevent the death;
(iv) if a person takes his or her own life, whether this was in whole or in part because the risk of their doing so was not recognised by those acting on behalf of the state;
(v) any other factor relevant to the circumstances in which the deceased came by his or her death..
Amendment 70, in clause 5, page 4, leave out lines 3 to 9.
Clause stand part.
Amendment 121, in schedule 4, page 129, leave out lines 27 and 28 and insert
the provisions laid out in sub-paragraph (1A) shall apply.
(1A) Those provisions are
(a) the coroner may report the matter to a person who the coroner believes may have power to take such action;
(b) the coroner may make recommendations to the person referred to in sub-sub-paragraph (a);
(c) the coroner may report the matter and recommendations to the Chief Coroner, who must maintain a record of such reports and recommendations reported to him..
Amendment 35, in schedule 4, page 129, line 27, leave out first may and insert must.
Amendment 48, in schedule 4, page 129, line 30, at end add
(3) The senior coroner may then request the relevant person to submit, within 3 months, a full update on any action he has taken, or alternatively detail the reasons for any failure to take action.
(4) The senior coroner must at the end of each year forward all reports and updates to the Chief Coroner, who must present them to Parliament..
Amendment 122, in schedule 4, page 129, line 30, at end add
(3) The Chief Coroner shall once a year make a report to the Lord Chancellor of the reports and recommendations made by senior coroners in the previous 12 months..
Amendment 93, in schedule 4, page 129, line 30, at end add
7 (1) A person who fails to comply with the duty in paragraph 6(2) commits an offence.
(2) A person guilty of an offence under this paragraph is liable on summary conviction to a fine not exceeding level 5 on the standard scale.
8 (1) A senior coroner shall send to the Chief Coroner a copy of all
(i) reports referred to in paragraph 6(1); and
(ii) responses referred to in paragraph 6(2).
(2) The Chief Coroner shall maintain a register of all the material he receives pursuant to sub-paragraph (1) and shall from time to time publish a summary of
(i) the reports and responses referred to in sub-paragraph (1) subject to appropriate protection of confidential data; and
(ii) his analysis of the conclusions to be drawn from them with regard to reducing the risk of death.
(3) The Chief Coroner shall send copies of the reports he publishes pursuant to sub-paragraph (2) to
(i) the Lord Chancellor; and
(ii) Parliament..

Henry Bellingham: This is a key clause, because it sets out the purpose of investigations. Our amendments 35 and 48, along with the Liberal Democrat amendments and the one in the name of the hon. Member for Stafford, are mainly about trying to learn lessons. They all aim to ensure that future deaths are prevented.
Amendment 39 is a legal aficionados point. It involves quite a complicated argument, with which I do not plan to detain the Committee for long, but we need a full explanation from the Minister. Maybe this is an opportunity for the hon. Member for Cambridge to chip in, because he was a distinguished law fellow at Cambridge university. If I had been taught by him, my law degree might have been slightly better than it was.
Clause 5(2) seeks to codify into statute the provisions of R on the application of Middleton, the HM coroner for the western district of Somerset and Avon 2004 2AC182. The Government say that 5(2) is needed to ensure compliance with ECHR article 2, which relates to the states responsibility to ensure that its actions do not cause the death of citizens. The BillI find this surprisingdoes not define the precise circumstances when a coroner should conduct an article 2 investigation. I listened carefully to what AndrÃ(c) Rebello had to say to the Committee in the evidence-gathering session:
I have concerns regarding matters to be ascertained at an inquest in clause 5, because the draftsman has taken the words of Lord Bingham in the Middleton case and enshrined them in clause 5(2)...It is far better to leave clause 5 as how, where how means in some inquests by what means and in other inquests by what means and in what circumstances,
which is, of course, what article 2 would lay down. He takes the view that
It would be far better to leave out clause 5(2), so that how means whatever the common law says it means for the time being. If we are now reforming the 1887 legislation, I am fairly sure that in 2051 the law will have developed somewhat, and I do not think it right to tie the hands of the European Court and the House of Lords with regard to developments.[Official Report, Coroners and Justice Public Bill Committee, 3 February 2009; c. 56, Q119.]
I had a word with Mr. Rebello afterwards, and I have looked at the judgment that he quoted. I have also spoken to learned sources, who take the view that the Government should explain why they feel that AndrÃ(c) Rebello is wrong and that subsection (2) should remain in the Bill.

Tim Boswell: Before my hon. Friend sits down, will he reflect on whether subsection (2) would require a senior coroner to take a view as to the applicability or otherwise of the convention rights before any investigation has taken place? That would require, with the greatest respect, a degree of legal expertise and interpretation, which might give rise to further litigation on whether those convention rights had been so considered.

Henry Bellingham: That would be a lawyers dream. There would be cases going on appeal and possibly all the way to the House of Lords time and time again. I hope that the Minister can explain to the Committee, possibly in laymans language, why it is necessary to keep that subsection.
I come now to the nub of the clause and the crux of amendments 35 and 48, which relate to paragraph 6 of schedule 4 on page 129 on
Action to prevent other deaths.
Paragraph 6(1) states:
the coroner may report the matter to a person who the coroner believes may have power to take such action.
We suggest that rather than may, the coroner must make that report. There should be a statutory duty on the coroner.
My hon. Friends and I have put a lot of work into drafting amendment 48, which is the key amendment. It would add to paragraph 6:
(3) The senior coroner may then request the relevant person to submit, within 3 months, a full update on any action he has taken, or alternatively detail the reasons for any failure to take action.
(4) The senior coroner must at the end of each year forward all reports and updates to the Chief Coroner, who must present them to Parliament.
That may not be brilliantly drafted, but it makes the point loud and clear. When there is a tragic death, lessons must be learned.
We have all come across constituency cases where families have lost loved ones. In the past few years, there have been two appalling fatal accidents in my constituency. Very near the county boundary between Norfolk and Cambridgeshire there is a junction where a small road called Broad End road crosses the A47. Of course, the families involved realise that nothing can be done to bring their loved ones back. One case involved a young lad on a motor cycle who was minding his own business on the main road and a van pulled out at what is a notoriously dangerous junction.
On a more recent occasion, four youngsters in a car navigated from the minor road on to the major road, trying to cut across itit was night, it was raining and the traffic was moving at high speed. I think that the girl driving the car had only been driving for a number of months. There was a car travelling at very high speedway in excess of the speed limitand although that junction has broken white lines, they are not double white lines, so cars can legally overtake on the junction. It was a tragic accident. The family realise that nothing can bring their loved ones back, but they want closure above all else. In that case, they felt that the driver of the other vehicle should have been prosecuted for causing death by dangerous drivingthe matter is ongoing, and I will not comment further because it is a sensitive issue.
The family also want lessons to be learned. They take the viewthey feel very strongly indeedthat in the case of the Highways Agency, the coroner should have a duty to report to the relevant person. There should then be a duty on that authoritybe it the Highways Agency, the Health and Safety Executive, the Department of Transport, the Ministry of Defence or any number of different Government bodiesto report back on what improvements could be made.
I am concerned that the Bill as drafted does not go far enough. Let us consider what various organisations have said to us. I refer again to our friend AndrÃ(c) Rebello. In his evidence to the Committee, he talked about the rule 43 provision. We all know about rule 43. He said that the Bill as it stands is inadequatehe was referring to the relevant scheduleand that there are no sanctions for failing to respond. That is very poor, given that learning lessons is one of the most important parts of coronial jurisdiction. He certainly feels strongly that we can learn quite a lot from what happens overseas. For example, in Canada and in Victoria, which he mentioned
Mr. Kidneyrose

Henry Bellingham: I will give way to the hon. Gentleman as he has tabled a similar amendment. Hopefully between us, we will be able to make some progress, perhaps even by voting on one of the amendments.

David Kidney: Does the hon. Gentleman agree that his amendments do not include the sanction that Mr. Rebello pointed out is not in the Bill? What does he think would be the best sanction?

Henry Bellingham: We do not include a sanction, but our amendment includes a statutory duty. Legal action could then result from that. I am tempted by the hon. Gentlemans suggestion that a firmer sanction should be laid down in the statute. There should be a statutory duty on the coroner to report at the end of each year to the chief coroner, who would then present a report to Parliament. It is vital that the knowledge gleaned from those inquests does not go to waste.
Liberty is another organisation that has briefed us at some length. It talks about schedule 4 and says that
A senior coroner who believes that action should be taken to prevent the reoccurrence of fatalities may report the matter to the relevant authorities.
Our amendment would replace the word may with must. Liberty goes on:
There is no responsibility to report findings, and there are no guidelines on cases where recommendations should be made. Furthermore, coroners have no power to ensure their recommendations are implemented, and there are no duties on the part of other agencies to respond or institute changes.
In the past coroners have been found to be making identical findings and recommendations which were not implemented.
Anyone who has been following the coronial system over the past few years will know that to be the case. Liberty goes on:
The previous draft Coroners Bill gave a nod towards this problem with provision made for the Chief Coroner to report to Parliament so that contentious issues could be scrutinised.
I submit that our amendment takes care of that, although not with quite the same wording as the draft Bill. What we are saying in our amendment is that the senior coroner must, at the end of the year, forward all reports and updates to the chief coroner, who must then present them to Parliament. There would be an annual report from him and he would be able to identify the different types of lessons that can be learned from a multiplicity of types of deathsfor example, on the road, drowning or other accidents that take place and result in tragic deaths.
If one considers what happens elsewherefor example, in New South Wales recommendations are an integral part of the inquest process and are logged in a detailed document at the end of the inquest. The document is then available to the public and is tabled in Parliament. Doing so obviously exerts substantial political pressure on the Government to take action. In Ontario, for example, the inquest jury gives a verdict and makes recommendations, which are published centrally and sent to all the parties involved. Implementation is monitored annually by a department of the chief coroners office. Although our amendment does not go as far as the provisions in Victoria, New South Wales or Ontario, it is a sensible move in the right direction. It would put a statutory duty on the coroner to make those reports. It would put the duty on the person involvedthe Government agency, the Department or whatever it might beto respond. That would mean that the report came through to Parliament.
As the Bill stands, there is nothing that will enable that to happen. My concern is that lessons will not be learned. I shall conclude with another example from my constituency. Norfolk is well known for its long sandy beaches, but the tides can be fairly perilous. On a beach at Brancaster, drownings have resulted from youngsters taking a risk and going out to different sand banks. One particular sand bank has an appealing shipwreck on it. A tragic case of drowning took place during the time that my predecessor George Turner was MP for North-West Norfolk. He raised the matter in Parliament and was determined that lessons should be learned. Of course, there was an inquest and the coroner made various recommendations, but that is where it ended. I do not believe that any of the key authoritieswhether it was the Crown Estate, Natural England, the National Trust or the parish councilwere given any proper advice about how to prevent drownings in future. Perhaps advice could have been given on signage, how to work with other parish councils or how to look at best practice elsewhere in the country.
Mercifully, that tragedy has not been repeated, but the lessons that could and should have been learned from that incident were not properly learned or processed in a way that reassured the family. Above all, the family want closure and for lessons to be learned to prevent future deaths. Let us improve the Bill so that that can be achieved.

David Kidney: It is a pleasure, Mr. Cook, to serve on the Committee under your fair and firm leadership. Clause 5 is subject to paragraph 6 of schedule 4. As the hon. Member for North-West Norfolk said, where a coroner conducts an inquest and feels that lessons could be learned from a particular death under investigation that, if applied more generally, could reduce the risk of deaths in the future, further action should follow. My amendment is in part to make sure that further action does follow, so that we can reduce the risk of death in future cases. I am sure that the public would want us to do so.
Amendment 93 is my own work and I have had no outside help, so I instantly accept that there are probably flaws in the drafting. There are two points to my amendment. I intervened on the hon. Gentleman in relation to the first point, which is the question of sanctions. Since S.I. 2008/1652 was introduced by the Under-Secretary of State for Justice, my hon. Friend the Member for Lewisham, East last year, there has been a duty on people who receive a report from a coroner to say something in response, but so what?
What if people do not respond to the coroners reportand some people are not responding to it at present? In theory, if the Bill became law, the chief coroner could go to the High Court and seek an injunction to make someone comply with the duty and give an answer. Having spent thousands of pounds of taxpayers money, the chief coroner could get the answer, Thank you, we have received the report, we are going to do nothing about it. We need to make people sit up and take notice, so my proposal is that it should be a criminal offence not to respond to the coroners report. That might sound a bit harsh, but it would get peoples attention and mean that in most cases we would get a response. That does not go as far as the Liberty proposal, for example, and make people carry out the coroners recommendations, but we should hear the other sides response before we conclude what more should be done. It is important to have their attention and to make them respond.
My amendment is inadequate in that it does not specify who the criminal is if the offence is proved. If the criminal were a hospital trust or a multinational corporation, who would be convicted? I have not dealt with that detail. That is something that I would have to rely on the Minister, with her hoards of civil servants, to take care of, if she agreed with the principle of it being a criminal offence.
One alternative, of course, would be to go down the route of a civil penalty and say that someone who does not respond could have a civil penalty imposed on them. That may be the more modern and progressive way. It would perhaps not have the negative implication of someone ending up with a criminal record. However, it would open up further questions about who would impose the civil penalty. I find it difficult to envisage that the chief coroner would welcome such a role.

Tim Boswell: By way of a helpful suggestion, has the hon. Gentleman even considered the possibility that the coroners court, or the coroner, might be able to hold the person in contempt for not responding?

David Kidney: That is a helpful point. I like the idea of the coroner summoning someone to court to explain why they did not respond and to make them give their answer in the court. Such inconvenience might get their attention too, so there are many ways to do it. The point is that the Bill, as drafted, has no sanction at all. I would like the Minister to take account of the many people who have said that it should.
On the issue of reporting, it is important that the public, decision makers and policy makers understand the trends behind the facts that coroners are unearthing. It is vital that Parliament sees the results of the coroners recommendations, the persons responses and any analysis of trends that the chief coroner is able to give. It is vital that Parliament has a report from the chief coroner that shows that to us. It may be that an annual report is too restrictive, because if something is urgent and action is urgently required, it would be reasonable for the chief coroner to alert Parliament to a particular set of circumstances, or a particular trend, in a short space of time. The chief coroner should not have to wait for an annual report in order to alert us to it.
In the draft coroners Bill, in clause 59, there was a provision for the chief coroner to deliver an annual report to the Lord Chancellor and an obligation on the Lord Chancellor to lay that report before Parliament. It is disappointing to see no reference to that provision in the Bill. The House of Commons Library, in its research paper 09/07, says that it is the Governments intention
that this would be dealt with in regulations under clause 33(3)(d).
That is drawn in the most general of terms and does not specifically cover this point.
If the Minister is happy to leave it to statutory instruments to require the chief coroner to give the Minister a report, that is finethe Minister can have that option. However, I represent Parliament and the people, and Parliament wants its report on the face of the Act, whether or not the Minister makes statutory regulations requiring that a report be made to the Minister.
The last line of my amendment says that the chief coroner must give the report to Parliament. That is particularly important. Even if the Minister does not want primary legislation to receive the report herself, can she bear it in mind that Parliament wants it?

Jennifer Willott: Somewhat worryingly, I agree with almost every word that the hon. Gentleman has just said. I also agree with almost everything that the hon. Member for North-West Norfolk said. There are clearly issues here which have broad support on both sides of the Committee. Particularly with regard to the group of amendments relating to reports by coroners, there is a strong view on both sides of the Committee that, at the moment, what is in the Bill does not go far enough. We all have different ways of suggesting how it could be changed, but there is a strong view that the provision needs to be beefed up in some way and strengthened.
First, I want to return to the issue of narrative verdicts. The reference in clause 5(2) that enables juries and coroners, when looking into article 2 deaths, to make a narrative verdict is welcome, but it does not go far enough. We have had a lot of evidence from witnesses last week, and I am sure that members of this Committee have spoken to constituents who have been affected. There is a general desire for a lot more flexibilitymore than the Bill currently providesto be built into the system.
Narrative verdictswhen a jury or coroner expand on the information that is providedcan be incredibly valuable both for the family of the victim, and also for those who have an interest in the case. They help in genuinely understanding what happened, why and what the circumstances were. The hon. Member for Bridgend has raised the issue of psychological inquests. In some ways, it is a similar idea that a broader amount of information should be provided and that, following an inquest, there should be flexibility for that information to come out and be published, so that the first level of lessons being learned can start to take place.
It is clear with article 2 deaths that there is a requirement for the Government to allow, where necessary, broader narrative verdicts. That relates to, for example, whether there are systematic failings that were a factor in the death or, in the case of a suicide that takes place in the hands of the state, if that happened because the danger was not recognised by authorities. There are a number of other cases, and although they were not in the hands of the state, there may have been circumstances and incidents in the past that should have been identified. That could be where somebody was at a particularly high risk of suicide and it did not get picked up, or where somebody has died in such a way that significant lessons could be learned. Given that, we are proposing in amendments 112 to 114 to enable juries and coroners to provide a narrative verdict where they feel that there is a need to or that they want to. That is not a requirementit is making additional flexibility and giving juries and coroners the ability to do that.
That goes hand in hand with amendment 70 which deletes lines 3 to 9 on page 4. It is, in our view, an unprecedented gagging order, which basically restricts juries from expressing views or explaining the circumstances of a death beyond the bald facts laid out in paragraphs (a) to (c). I believe that it is not justifiable to gag a jury or a coroner. By definition, jury inquests consider the matters most relevant to wider public interest, because of the type of deaths where jury inquests are initiated. I feel that clause 5(3) interferes with the ability of juries to undertake what should be considered as their function and duty, sitting in coroners courts. Removing it would enable narrative verdicts to be introduced, when the jury feels that it is necessary.
I want to highlight that we intend to press amendment 114 to a Division, because it is an area that we feel strongly about. We have had a lot of evidence that narrative verdicts can offer significant benefits, and we would like to flag up to the Government that the Bill is too restrictive. We would like to enable coroners and juries to make their own decision about whether to expand on a verdict, when they feel that that is necessary.
On the issue of the senior coroners reports, which has already been discussed at length, there is a clear need to identify patterns of problems and systemic failings. There are strong views on both sides of the Committee that that is an issue that needs to be beefed up. As I commented on an earlier clause, given that there is no national coroner service, there is an even greater need to ensure that there are measures in the Bill for recommendations and reports to be centralised in either a database or some sort of system, so that patterns can be identified. Our proposal is that senior coroners reports would include recommendations that would be sent to the chief coroner, who would maintain it centrally, and it would be reported to the Lord Chancellor annually. The hon. Members for Stafford and for North West Norfolk have advanced other proposals, all of which attempt to achieve the same end, and we are happy to support whatever measure achieves the ultimate goal.
On the point made by the hon. Member for Stafford, since bodies are supposed to respond to coroners reports, we shouldif that is done fullybe able to start gathering a full picture and identify where there are problematic patterns of behaviour and broad health and safety breaches that are repeated across the country. There has been a problemI am sure that all hon. Members agree with thiswith the implementation of some recommendations made in previous public inquiries, where there was no proper monitoring to ensure that they were implemented. We have fantastic public inquiries that come up with strong recommendations, which are then not implemented, and there is very little monitoring of what happens. The amendments would ensure that that would not happen in coroners courts, and nobody could get away with not noticing that something had not happened. Recommendations would be gathered centrally, and the chief coroner would have to report to either the Lord Chancellor or Parliament, so that there would be better accountability and transparency of what is happening to the reports and the responses on the recommendations that have been raised.
From my experience of talking to and dealing with coroners, I know that they are extremely experienced and are very good at spotting patterns, consistent problems and systematic failings. At the moment, we are not taking advantage of their expertise and knowledge. The amendmentswhichever ones the Government may like to makewould enable that knowledge and expertise to be better utilised and the recommendations to be better implemented and monitored. That would enable Parliament and the Government to have a much better understanding of the lessons that need to be learned and to be able to see which public bodies are not implementing the recommendations. I hope that the Government will take into account the views that have been expressed on both sides of the Committee, and we will press amendment 114 to a vote.

Tim Boswell: I have little to add to the debate except warm assent to almost all the points that have been made on both sides of the Committee. On the utilityor otherwiseof an inquest, the self-evident point that sometimes needs to be gently put into the minds of bereaved people is that whatever process we have, it will not reverse the process of death. The rather more general point is that the inquest may either be unable to reach a firm conclusion or reach one where perhaps there are no villains and nothing can be generalised from the particular proceedings. However, I think that the concern of all members of the Committee who have spoken is that if a pattern is building up, it should be the subject of a report. There should be a system that eventually produces at least an opportunity to capture the attention of Parliament.
As I have mentioned at least once in these deliberations, I have had a fairly long association with the British Lung Foundation and have taken an interest in mesothelioma. Much of this debate is about good practice. We will not really, in debating legislation, be able to introduce the requirements for good practice, except that I hope that the Minister has noted them.
The British Lung Foundation identified a particular issue in one of its inquiries. Two years ago, in February 2007, it published a report called An unnatural death. One of the striking things about it was that it highlighted the lack of consistent practice among coroners in responding to deaths from mesothelioma. There is a variety of circumstances, but the point that is germane to this debate is that there needs to be some consistency of reporting, so that the nature of what is happening is clearly available to the chief coroner and to the decision makers.
I happen to know that the Department for Work and Pensions has an elaborate model and a database relating to all mesothelioma deaths and is able to predict the likely pattern of mortality over perhaps the next 40 or 50 years. If that were to be questioned by what was happening at inquests, and if the coroners accounts were sufficiently coherent to build up a pattern of a change in the epidemiology, it would be a matter of public interest.
Clearly, if we can use these narrative judgments or reports in the widest possible context, we can draw the attention of people in government or in public life to a variety of circumstances in which things might be better in the future, but one needs the facts to do that, so one needs a certain coherence in reporting. One needs a readiness to report and then, as the hon. Member for Stafford, among others, has said so clearly, an ability to respond on the part of the various interested persons for whom that report was made. The world is littered with White Papers and good intentions, none of which has ever been acted on because we have moved on to the next thing. I would take the process a stage further back and say that we need consistency and coherence in reporting.
The only other point that I shall add, which again is more a matter of administration than legislation, is that the chief coroner needs to be very alert. The chief coroner possibly needs a chief information officer to complement his activities and to look at the pattern of information as it comes in, to be able to analyse and cross-analyse it and to draw peoples attention to what is developing. Let me give an example. It is often easier to say that cars are all the same these days, but there might be a particular pattern of failure in a particular marque. Perhaps some component is wrong, or it might be brake failure or whateversomething more than one would normally expect by the nature of the accident. That should be flagged up and then someone should do something about it. I think that there is a common will on both sides of the CommitteeI certainly wish to include the Minister in this, in anticipation of her remarksto do something about that, but we should set up the best possible arrangements.

Madeleine Moon: It is difficult to rise to speak in this Committee when one is not a lawyer and one is surrounded by so many lawyers who speak so wisely and graphically about their involvement with the law. My background is much more with individuals and their personal experience of life. That is what I draw on when I consider the discussion that we have had today.
When I talk to families who have experienced inquests, I find that part of what they looked for from the inquest is some resolution to their grief. They look for answers and explanations as to why. It has been suggested that narrative verdicts are a particularly helpful way of providing that, in that they give a longer discussion and explanation of what may have occurred. Equally, narrative verdicts have caused distressas have open verdictsto families that were distressed by things that were said and placed in the public domain without a full understanding of the individual, their life and their background.
I urge caution on seeing open and narrative verdicts as potentially useful ways forward. They also have risks in terms of suicide data collection, because in the case of narrative verdicts, they are not recorded as suicide and in the case of an open verdict it is down to a clerk in the Office for National Statistics to trawl through the information and decide whether it was a death by suicide. We have some problems there. I heartily concur with the suggestion that someone must be held to account and that where we can identify patterns of information and patterns of failure, someone clearly needs to be responsible for taking action. Bridgend was identified as a centre where there had been a cluster of suicides. In fact, Bridgend did not have the highest number of suicides across Walesit was quite low down. What we had was a huge problem building up across Wales that was not being identified.
I also urge caution regarding the suggestion that the report must always come to Parliament. With devolved Administrations, health and transport are devolved issues. If the area of problematic behaviour or failure that needs to be identified is not within the purview of Parliament but within that of a devolved Administration, such as the Welsh Assembly, there may well be difficulties if the report comes only to Parliament, and we need to take that into account.
While I am on my feet, I must quickly mention the charter for the bereaved, which is extremely welcome. Families have told me that the judicial atmosphere of the coroners courtwe have heard the description of the court based in central Cardiffis horrendous. Imagine going there within six months, eight months or a year of the death of a close family member and having to face the welcome of a desk sergeant who tells one where to go, a judicial atmosphere, a sense of stigma and almost a sense of guilt. Families have talked to me about an invasion of privacy. Because of the need to pull together social and personal information, there is a feeling that there is almost a desire to find the dysfunctional nature of a family or individual, which can be particularly distressing in the full glare of media coverage.
I particularly welcome clause 5(3):
Neither the senior coroner conducting an investigation under this Part into a persons death nor the jury (if there is one) may express any opinion.
Certainly, families have expressed concern about the following difference in procedure, and I would welcome a comment from the Minister. A coroner can express an opinionand, indeed, hold a press conference in which to give an opinionwhereas a judge hearing a court case cannot do that. If, as my understanding is, that provision would preclude a coroner from doing that, families who have spoken to me would welcome it.
Briefly, on delayed inquests, particularly when there has been a tragic death, we must be mindful of intruding into the grieving process and of the fact that, for some families, the process is delayed and damaged by the need to return to courtsometimes, two or three years laterto hear graphic details of their family members death. There must be greater awareness of the damage that we can do to individuals through delayed inquests. The charter is an opportunity to help and prepare families prior to the inquest, and an opportunity to give them guidance and support through it, which is something that we must all welcome.

David Howarth: May I comment briefly on amendment 70? It addresses the principle of the matter, which is the restrictionthe muzzlingof the jury. As the hon. Member for Bridgend has said, in some circumstances a jurys extended account of the circumstances in which the death came about, or further information about how such deaths might be prevented in the future, might not always help. However, the question is whether the jury should be told that it should never be allowed to do anything of that sort. The hon. Lady shakes her head, and I think that she agrees that the jury should have that power, as should the coroner in cases without a jury. That is the principle of the debate about clause 5. I shall ask for a vote on amendment 70, so if my hon. Friend the Member for Cardiff, Central would be so kind as to withdraw her request for a vote on amendment 114, it would help, because amendment 70 is far more the matter of principle.
The hon. Member for North-West Norfolk mentioned amendment 39, the meaning of subsection (2) and the question raised by Mr. Rebello at our evidence sessions. Mr. Rebello is wrong, however. The Bill makes sense, although it is rather mean. It tries to provide for minimal compliance with human rights standards for the time being. Mr. Rebello read subsection (2) as meaning that when the Bill was passed, we would somehow decide the human rights requirements for an article 2 hearingwe would fix themand tell coroners courts what they must do. He felt that that would be a rigid way of doing it, and that it would not necessarily comply with human rights law. But that is not what the provision in subsection (2) means. It means that a coroner conducting an investigation must apply human rights law as it stands, so there is no list of human rights requirements that is drawn up once and for all. The subsection also applies to every investigation, so a coroner making an investigation must ask himself whether the restrictions in subsection (1) would violate the human rights standards for the time being. If they would, the coroner would have to apply subsection (2) and go beyond it to ask in what circumstances the death occurred, which is the broader requirement in the Middleton case.

Tim Boswell: May I use the hon. Gentlemans comments as an opportunity to ask the Minister whether any training on the human rights convention and standards is envisaged for coroners? It is a complex field, and it may not be within their normal purview of activity.

David Howarth: That is an interesting question. I suspect that coroners, like all members of the judiciary, receive human rights training already. Magistrates certainly do, so I would be surprised if coroners did not. All public officials are bound by the Human Rights Act. Mr. Rebellos criticism of clause 5(2)that it is inflexibleis incorrect. If there is a criticism, it is that it is minimalist. Instead of admitting the general principle that the broader circumstances of a death should be investigated, at least where the state is involved, but possibly in other cases as well, clause 5(2) effectively states, rather mean-spiritedly, Well, if not going further would violate human rights, go further, but otherwise just stick to clause 5(1). That is the criticism, not the argument that Mr. Rebello stated in the evidence session and that the hon. Member for North-West Norfolk repeated just now.

Frank Cook: May I ask the hon. Gentleman to resolve the differences with his colleague while the Minister is responding to the debate? In any case, any amendments requiring a Division will need to be moved formally, at which point a decision can be made.

Bridget Prentice: I shall attempt to respond in some detail and explain what clause 5 is about. In so doing, I hope that I can give some succour to some of the amendments, although not all of them.
Clause 5 outlines the matters that a coroner is legally obliged to ascertain during the course of the investigation. It does not prescribe what opinions he may express as a result of that investigation. People might have that impression because they are focusing too narrowly on clause 5 and not taking it in conjunction with clause 10 and paragraph 6 of schedule 4. In that context, it can be seen that coroners may make such comments at the end of their investigations. However, the purpose of a coroners investigation is not to apportion blame, but to ascertain fact. Any inquest forming part of an investigation is inquisitorial and collaborative; it does not seek to apportion blame or to establish legal liability.

David Howarth: Clause 10 puts in place yet another restriction on what the coroner or jury can say. Clause 10(2) states that whatever is said cannot
be framed in such a way as to appear to determine any question of...criminal...or...civil liability.
The clause seems to be restrictive, rather than expansive.

Bridget Prentice: I just said that the purpose of a coroners investigation is not to establish criminal liability, but fact, so I do not think that I am being inconsistent.
Amendment 39 relates to article 2 of the European convention on human rights and the Human Rights Act 1998. The hon. Member for Cambridge is right that there was a misunderstanding among some coroners giving evidence to the Committee. Subsection (2) provides the necessary flexibility to take into account future judgments changing or extending the circumstances in which convention rights apply. Coroners are already being trained in the application of the convention and being kept up to date with case law and so on. Also, regulations will be made dealing with training, which we can discuss under clause 28.

Tim Boswell: To state the obvious, has the Minister not noticed that the fact that the senior coroner giving evidence to this Committee, who presumably is as skilled as, if not more skilled than, many of his colleagues, has difficulties interpreting the clause suggests that more attention needs to be paid to training and information than has hitherto been the case?

Bridget Prentice: I accept the hon. Gentlemans comments. Perhaps some revision and homework may need to be done in order to ensure that coroners fully understand what article 2 and the convention are about.
By their very nature, article 2 inquests probably need to be more wide-ranging than ordinary inquests. There are between 200 and 300 inquests that involve article 2, which is about 1 per cent. of all inquests that are heard each year. Such inquests are expected to address matters relating to the broad circumstances surrounding the death, rather than merely the who, where, when and how that would be required in the course of a normal inquest. If we were to remove clause 5(2), that would leave the Bill lacking in clarity as to what is required in article 2 inquests over and above what is normally required. Also, by removing clause 5(2), we would be ignoring existing case law. I hope that the hon. Member for North-West Norfolk withdraws that particular amendment.
Amendment 70 would remove from the face of the Bill the obligation not to express an opinion with respect to the matters to be ascertained under subsections (1) and (2). That obligation is there because those matters are matters of fact. There should be no room for additional opinion in determining those matters. Additionally, coroners should probably not be giving press conferences to discuss individual cases. They may, of course, talk about policy in general, but it is usually bad practice to be having press conferences about individual cases, regardless of the circumstances of those cases.
Subsection (3) contains the proviso that it is
subject to paragraph 6 of Schedule 4.
That means that coroners can make reports regarding the action to be taken to prevent future deaths, which is similar to reports that are currently under rule 43. That gives the coroner sufficient scope to make detailed reports on things that they think should be brought to the attention of those who have the power to take action to prevent further deaths.
There is also scope within the associated rules under clause 34 for narrative verdicts, for which the hon. Member for Cardiff, Central made an eloquent plea. However, my hon. Friend the Member for Bridgend gave an equally eloquent response on why such verdicts might not be particularly helpful to bereaved families. Given that the central aim that we are looking to achieve here is to make sure that the grieved families get the best possible service, it is a difficult area, because in some instances a narrative verdict can cause further distress. However, I accept that phrases such as death by misadventure do not really tell anyone very much about exactly what happened. Therefore, we have to give coroners some flexibility to express exactly what happened in a more rounded fashion than short versions such as death by misadventure or even death by suicide.
Not surprisingly, amendments 112 to 114 take the coroner further down the road of expressing an opinion, possibly even attributing blame and assigning civil or criminal liability. That is not the purpose of a coronial investigation.

Jennifer Willott: Does the Minister accept that the amendments would not do that, because such matters would still be subject to clause 10? Clause 10(2) makes it clear that the coroner cannot determine criminal or civil liability. Therefore the coroner or the jury will be able to provide more detail, but not to accord blame.

Bridget Prentice: Amendments 112 to 114 would tempt a coroner down that route. That is a problem with those amendments. However, a coroner can properly give their views in any report to prevent further deaths, which is an important part of what they do. That point is covered in paragraph 6 of schedule 4. The changes made last year under rule 43 gave coroners much wider discretion to make whatever comments they think are necessary to ensure that improvements are made as a result of their investigations.
Amendment 35 would introduce a duty to report to the relevant person, whereas it is currently discretionary. I see some merit in that point and will reflect on it. Amendment 48 would give the coroner the power to request that the relevant person submit an update on their actions within three months. It would also introduce a duty on the coroner to forward all updates to the chief coroner at the end of each year, who would lay them before Parliament. There is merit in that, and I will reflect further on it.
The same point applies to amendments 121 and 122 and the last part of amendment 93, which was tabled by my hon. Friend the Member for Stafford. The public expression of coroners findings is important in ensuring that deaths do not occur as a result of nobody taking cognisance of what a coroner has found. Those amendments would strengthen the obligations on coroners and on the relevant persons to prevent future deaths.
I will give an example of something that happened under rule 43 and the current discretionary system. A coroner issued a rule 43 report into a death from injuries incurred on a railway line. He asked for a response to ensure that the issues found in the investigation did not recur. British Transport police responded and outlined the action that it had taken in relation to the circumstances of the case. It also listed a further six actions that it had taken over an 18-month period to improve its investigations of deaths on railways. It was keen to keep in touch with coroners to improve investigative processes. Even under the rule 43 system, we are seeing improvements in how people respond to causes of death reported by coroners.
I understand the reasoning behind the amendments that I have mentioned. They would not only ensure that coroners and organisations take seriously the responsibility of preventing further deaths, but would give the public confidence that that is the case. In this area, as in many others, people express the view that the hon. Member for Daventry gave: they understand that they cannot bring their own loved one back, but they do not want to see the same thing happen to someone else. If they can see that the response is taken seriously, it helps them to obtain closure and get through the bereavement process.
I will reflect further on the amendments that I have outlined, including the last part of amendment 93 tabled by my hon. Friend the Member for Stafford. I cannot commend the idea of the criminal sanction at this stage. I am not yet convinced that even the threat of a level 5 fine would be a sufficient deterrent. However, the indication from the changes in rule 43 show that organisations and the relevant authorities are beginning to take their responses seriously.

David Kidney: After listening to the debate, does my hon. Friend like the idea that the coroner could summon someone to court, if they did not answer the report?

Bridget Prentice: Yes, I do, but I am not sure whether it can be put into the Bill and will have to consider the matter. Coroners need to be given all possible tools to ensure that their investigations are thorough and can reach a proper conclusion. That is something that we might consider further. On that basis, I ask the hon. Member for North-West Norfolk to withdraw the amendment and the hon. Members for Cardiff, Central and for Cambridge to decide which ones they wish to vote on.

Henry Bellingham: I am mindful of the time. I am grateful to the Minister for her explanation of the ECHR and the Human Rights Act 1998. Obviously, the Opposition will have to return to AndrÃ(c) Rebello and take further advice on that. In the meantime, I am happy to withdraw the amendment.
I am delighted by what the Minister said about amendments 35 and 48. We are certainly not trying to pretend that amendment 48 is absolutely the best way to achieve those ends. If she can pick out the best of the Liberal Democrats amendment 121 and of amendment 93, tabled by the hon. Member for Stafford, the Committee will achieve exactly what it wants to achieve, which is to ensure that lessons are learned. On that basis, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendment proposed: 70, in clause 5, page 4, leave out lines 3 to 9.(David Howarth.)

Question put, That the amendment be made.

The Committee divided: Ayes 6, Noes 9.

Question accordingly negatived.

Clause 5 accordingly ordered to stand part of the Bill.

Clause 6

Duty to hold inquest

Tim Boswell: I beg to move amendment 103, in clause 6, page 4, line 14, at end insert
(2) Subject to subsection (1), the senior coroner responsible for the inquest must notify any interested person as soon as practicable that they are entitled to be assisted at all times by a legal representative.
(2B) Any legal representation shall be fully funded by the Legal Services Commission..

Frank Cook: With this it will be convenient to discuss the following: amendment 98, in clause 7, page 4, line 37, at end add
(5) In all cases where a jury is required for the purposes of an inquest, any interested person will be entitled to legal representation at the inquest, funded by the Legal Services Commission..
Amendment 102, in schedule 4, page 129, line 28, at end insert
(1A) Where the senior coroner considers that a report under this paragraph is likely to result from the inquest, the family of the deceased shall be entitled to legal representation funded by the Legal Services Commission..
Amendment 99, in clause 30, page 16, line 21, at end insert
(k) a decision not to allow legal representation funded by the Legal Services Commission to assist anyone falling within section 36(2)(a)..
Amendment 101, in clause 36, page 20, line 18, at end insert
(aa) a legal professional, if one has been appointed for the purposes of assisting the family;.
New clause 11Community Legal Service
(1) The Access to Justice Act 1999 (c. 22) is amended as follows.
(2) In Schedule 2, paragraph 2(1), after sub-sub-paragraph (e) insert
(ea) any coroners court..
New clause 12Legal representation of bereaved families
Where
(a) the inquest is to be held with a jury; or
(b) the deceased died whilst in custody or otherwise detained by the state; or
(c) the deceased died at a centre for provision of medical treatment, and the coroner has a duty to investigate the death under section 7(2); or
(d) any other parties participating in the inquest are assisted by a legal professional,
legal representation for bereaved families shall be funded by the Legal Services Commission..
New clause 13Legal representation of bereaved families (No. 2)
Means testing shall be waived for legal representation of bereaved families if
(a) the inquest is to be held with a jury; or
(b) the deceased died whilst in custody or otherwise detained by the state; or
(c) the deceased died at a centre of provision for medical treatment; or
(d) the deceased died whilst serving in the armed forces; and
(e) any other parties participating in the inquest are assisted by a legal professional..

Tim Boswell: I

The Chairman adjourned the Committee without Question put (Standing Order No. 88).

Adjourned till this day at Four oclock.